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<title>Disability Claim Form Claimant HTML 20130514</title>
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<meta name="author" content="Willie Visagie">
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<meta name="keywords" content=" , created by TeleForm 10.7 (10705) with Electric Paper HTML Plus&#178; Forms 5.0.220 , TeleForm HTML Plus&#178; Forms Electric Paper Informationssysteme GmbH, http://www.electricpaper.de" > 
<meta name="date" content="2013-05-14T17:47:08+17:47">
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<div class='div_text1'><div align='right'><span style='font: bold normal 9pt Arial;color:#000000;text-decoration: none'>DISABILITY, CRITICAL ILLNESS OR DREAD DISEASE CLAIM FORM <br /></span></div><div align='right'><span style=''>(TO BE COMPLETED BY CLAIMANT) <br /></span></div></div>
<div class='div_line_68'></div>
<div class='div_text53'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>SECTION 1 <br /></span></div>
<p /><label for='f106' class='clslbl'>Policy number</label>
<input type=TEXT value='' class='f106' id='f106' name='PolicyNumber' tabindex=1 title="Policy number" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,16);' onKeyDown = 'maxl(this,16);return EP_OKD(this ,event);'>
<p /><label for='f107' class='clslbl'>Claimant ID Number</label>
<input type=TEXT value='' class='f107' id='f107' name='IDNumber' tabindex=2 title="Claimant ID Number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,13);' onKeyDown = 'maxl(this,13);return EP_OKD(this ,event);'>
<div class='div_text2'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Policy number <br /></span></div>
<div class='div_text3'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>ID number <br /></span></div>
<div class='div_text55'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>1.1 <br /></span></div>
<div class='div_text57'><div align='left'><span style='font: normal normal 8pt Arial;color:#000000;text-decoration: none'>First name(s) of <br /></span></div><div align='left'><span style=''>claimant <br /></span></div></div>
<p /><label for='f127' class='clslbl'>First name(s) of Claimant</label>
<input type=TEXT value='' class='f127' id='f127' name='Claimants_First_Name' tabindex=3 title="First name(s) of Claimant" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,25);' onKeyDown = 'maxl(this,25);return EP_OKD(this ,event);'>
<p /><label for='f128' class='clslbl'>Claimant Age</label>
<input type=TEXT value='' class='f128' id='f128' name='ADAge' tabindex=4 title="Claimant Age" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,3);' onKeyDown = 'maxl(this,3);return EP_OKD(this ,event);'>
<div class='div_text6'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Age <br /></span></div>
<div class='div_text58'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Surname of claimant <br /></span></div>
<p /><label for='f146' class='clslbl'>Surname of Claimant</label>
<input type=TEXT value='' class='f146' id='f146' name='Claimants_Surname' tabindex=5 title="Surname of Claimant" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this ,event);'>
<p /><label for='f153' class='clslbl'>Claimant Address Line 1</label>
<input type=TEXT value='' class='f153' id='f153' name='Address_Line_1' tabindex=6 title="Claimant Address Line 1" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text18'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Line 1 <br /></span></div>
<div class='div_text23'><div align='center'><span style='font: normal normal 8pt Arial;color:#000000;text-decoration: none'>Residential <br /></span></div><div align='center'><span style=''>address <br /></span></div></div>
<p /><label for='f172' class='clslbl'>Claimant Address Line 2</label>
<input type=TEXT value='' class='f172' id='f172' name='Address_Line_2' tabindex=7 title="Claimant Address Line 2" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text19'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Line 2 <br /></span></div>
<p /><label for='f182' class='clslbl'>Claimant Address Suburb</label>
<input type=TEXT value='' class='f182' id='f182' name='Suburb' tabindex=8 title="Claimant Address Suburb" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 1);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text20'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Suburb <br /></span></div>
<p /><label for='f192' class='clslbl'>Claimant Address Town</label>
<input type=TEXT value='' class='f192' id='f192' name='Town' tabindex=9 title="Claimant Address Town" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text21'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Town <br /></span></div>
<p /><label for='f200' class='clslbl'>Claimant Address Province</label>
<input type=TEXT value='' class='f200' id='f200' name='Province' tabindex=10 title="Claimant Address Province" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text24'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Province <br /></span></div>
<p /><label for='f215' class='clslbl'>Claimant Address Postal Code</label>
<input type=TEXT value='' class='f215' id='f215' name='Code' tabindex=11 title="Claimant Address Postal Code" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text22'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Code <br /></span></div>
<p /><label for='f224' class='clslbl'> Claimant Work Telephone Number</label>
<input type=TEXT value='' class='f224' id='f224' name='Work_Number' tabindex=12 title=" Claimant Work Telephone Number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<p /><label for='f226' class='clslbl'> Claimant Cell Number</label>
<input type=TEXT value='' class='f226' id='f226' name='Cell_Number' tabindex=13 title=" Claimant Cell Number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<p /><label for='f227' class='clslbl'> Claimant Home Telephone Number</label>
<input type=TEXT value='' class='f227' id='f227' name='Home_Number' tabindex=14 title=" Claimant Home Telephone Number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<div class='div_text14'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Tel (w) <br /></span></div>
<div class='div_text15'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Cell <br /></span></div>
<div class='div_text16'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Tel (h) <br /></span></div>
<p /><label for='f233' class='clslbl'>Claimant Email Address</label>
<textarea class='f233' id='f233' name='Email_Address' spellcheck='false' tabindex=15 title="Claimant Email Address" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 1);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text17'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Email address <br /></span></div>
<p /><label for='f242' class='clslbl'>Income Tax office</label>
<input type=TEXT value='' class='f242' id='f242' name='TaxOffice' tabindex=16 title="Income Tax office" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<p /><label for='f243' class='clslbl'>Income Tax reference number</label>
<input type=TEXT value='' class='f243' id='f243' name='Taxno' tabindex=17 title="Income Tax reference number" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,13);' onKeyDown = 'maxl(this,13);return EP_OKD(this ,event);'>
<div class='div_text5'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Income tax office <br /></span></div>
<div class='div_text4'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Income tax reference number <br /></span></div>
<div class='f259_box'></div><p /><label for='f259' class='clslbl'>Claimant Marital Status - 1</label>
<input type=RADIO class='f259' id='f259' name='ADMaritalStatus' value='1' tabindex=18 title="Claimant Marital Status - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f260_box'></div><p /><label for='f260' class='clslbl'>Claimant Marital Status - 2</label>
<input type=RADIO class='f260' id='f260' name='ADMaritalStatus' value='2' tabindex=18 title="Claimant Marital Status - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f261_box'></div><p /><label for='f261' class='clslbl'>Claimant Marital Status - 3</label>
<input type=RADIO class='f261' id='f261' name='ADMaritalStatus' value='3' tabindex=18 title="Claimant Marital Status - 3" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f262_box'></div><p /><label for='f262' class='clslbl'>Claimant Marital Status - 4</label>
<input type=RADIO class='f262' id='f262' name='ADMaritalStatus' value='4' tabindex=18 title="Claimant Marital Status - 4" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f263_box'></div><p /><label for='f263' class='clslbl'>Claimant Marital Status - 5</label>
<input type=RADIO class='f263' id='f263' name='ADMaritalStatus' value='5' tabindex=18 title="Claimant Marital Status - 5" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f264_box'></div><p /><label for='f264' class='clslbl'>Claimant Marital Status - 6</label>
<input type=RADIO class='f264' id='f264' name='ADMaritalStatus' value='6' tabindex=18 title="Claimant Marital Status - 6" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text7'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Marital status <br /></span></div>
<div class='div_text8'><span style='font: 6pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Divorced <br /></span></div>
<div class='div_text9'><span style='font: 6pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Married <br /></span></div>
<div class='div_text10'><span style='font: 6pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Single <br /></span></div>
<div class='div_text11'><span style='font: 6pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Separated <br /></span></div>
<div class='div_text12'><span style='font: 6pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Widowed <br /></span></div>
<div class='div_text13'><span style='font: 6pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Other, eg common - law spouse <br /></span></div>
<div class='div_text26'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Do you currently have any other disability benefits (including both lump sum and/or premium waiver, accidental benefits (loss of limbs, etc) or sickness policies either effected by you privately or provided under your pension scheme? If so, please give details below: <br /></span></div>
<div class='f304_box'></div><p /><label for='f304' class='clslbl'>Do you currently have any other disability benefits? - 1</label>
<input type=RADIO class='f304' id='f304' name='AnyDisabilityBenifits' value='1' tabindex=19 title="Do you currently have any other disability benefits? - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f305_box'></div><p /><label for='f305' class='clslbl'>Do you currently have any other disability benefits? - 2</label>
<input type=RADIO class='f305' id='f305' name='AnyDisabilityBenifits' value='2' tabindex=19 title="Do you currently have any other disability benefits? - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text59'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Yes <br /></span></div>
<div class='div_text60'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>No <br /></span></div>
<div class='div_rect_317'></div>
<div class='div_line_318'></div>
<div class='div_line_319'></div>
<div class='div_line_320'></div>
<div class='div_text30'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>Amount of cover <br /></span></div>
<div class='div_text27'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>Company <br /></span></div>
<div class='div_text28'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>Policy number <br /></span></div>
<div class='div_text29'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>Type of policy <br /></span></div>
<div class='div_line_328'></div>
<div class='div_text31'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>Lump sum <br /></span></div>
<div class='div_text32'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>Monthly income <br /></span></div>
<div class='div_line_349'></div>
<p /><label for='f350' class='clslbl'> Company other disability Claims are held with.</label>
<textarea class='f350' id='f350' name='OtherPolicy_Comp_1' spellcheck='false' tabindex=20 title=" Company other disability Claims are held with." onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f351' class='clslbl'> Policy Number of other disability policy</label>
<textarea class='f351' id='f351' name='OtherPolicy_Number_1' spellcheck='false' tabindex=21 title=" Policy Number of other disability policy" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f352' class='clslbl'> Type of Policy</label>
<textarea class='f352' id='f352' name='OtherPolicy_Type_1' spellcheck='false' tabindex=22 title=" Type of Policy" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f353' class='clslbl'>OtherPolicy_LumpSum_1</label>
<textarea class='f353' id='f353' name='OtherPolicy_LumpSum_1' spellcheck='false' tabindex=23 title="OtherPolicy_LumpSum_1" onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f354' class='clslbl'>OtherPolicy_Monthly_1</label>
<textarea class='f354' id='f354' name='OtherPolicy_Monthly_1' spellcheck='false' tabindex=24 title="OtherPolicy_Monthly_1" onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f365' class='clslbl'> Company other disability Claims are held with.</label>
<textarea class='f365' id='f365' name='OtherPolicy_Comp_2' spellcheck='false' tabindex=25 title=" Company other disability Claims are held with." onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f366' class='clslbl'> Policy Number of other disability policy</label>
<textarea class='f366' id='f366' name='OtherPolicy_Number_2' spellcheck='false' tabindex=26 title=" Policy Number of other disability policy" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f367' class='clslbl'> Type of Policy</label>
<textarea class='f367' id='f367' name='OtherPolicy_Type_2' spellcheck='false' tabindex=27 title=" Type of Policy" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f368' class='clslbl'>OtherPolicy_LumpSum_2</label>
<textarea class='f368' id='f368' name='OtherPolicy_LumpSum_2' spellcheck='false' tabindex=28 title="OtherPolicy_LumpSum_2" onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f369' class='clslbl'>OtherPolicy_Monthly_2</label>
<textarea class='f369' id='f369' name='OtherPolicy_Monthly_2' spellcheck='false' tabindex=29 title="OtherPolicy_Monthly_2" onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f379' class='clslbl'> Company other disability Claims are held with.</label>
<textarea class='f379' id='f379' name='OtherPolicy_Comp_3' spellcheck='false' tabindex=30 title=" Company other disability Claims are held with." onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f380' class='clslbl'> Policy Number of other disability policy</label>
<textarea class='f380' id='f380' name='OtherPolicy_Number_3' spellcheck='false' tabindex=31 title=" Policy Number of other disability policy" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f381' class='clslbl'> Type of Policy</label>
<textarea class='f381' id='f381' name='OtherPolicy_Type_3' spellcheck='false' tabindex=32 title=" Type of Policy" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f382' class='clslbl'>OtherPolicy_LumpSum_3</label>
<textarea class='f382' id='f382' name='OtherPolicy_LumpSum_3' spellcheck='false' tabindex=33 title="OtherPolicy_LumpSum_3" onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f383' class='clslbl'>OtherPolicy_Monthly_3</label>
<textarea class='f383' id='f383' name='OtherPolicy_Monthly_3' spellcheck='false' tabindex=34 title="OtherPolicy_Monthly_3" onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f391' class='clslbl'> Company other disability Claims are held with.</label>
<textarea class='f391' id='f391' name='OtherPolicy_Comp_4' spellcheck='false' tabindex=35 title=" Company other disability Claims are held with." onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f392' class='clslbl'> Policy Number of other disability policy</label>
<textarea class='f392' id='f392' name='OtherPolicy_Number_4' spellcheck='false' tabindex=36 title=" Policy Number of other disability policy" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f393' class='clslbl'> Type of Policy</label>
<textarea class='f393' id='f393' name='OtherPolicy_Type_4' spellcheck='false' tabindex=37 title=" Type of Policy" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f394' class='clslbl'>OtherPolicy_LumpSum_4</label>
<textarea class='f394' id='f394' name='OtherPolicy_LumpSum_4' spellcheck='false' tabindex=38 title="OtherPolicy_LumpSum_4" onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f395' class='clslbl'>OtherPolicy_Monthly_4</label>
<textarea class='f395' id='f395' name='OtherPolicy_Monthly_4' spellcheck='false' tabindex=39 title="OtherPolicy_Monthly_4" onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text33'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>1.2 Are you entitled to any other benefit occasioned by your disability from: <br /></span></div>
<div class='f418_box'></div><p /><label for='f418' class='clslbl'>Are you entitled to any other benefit occasioned by your disability from your Employer? - 1</label>
<input type=RADIO class='f418' id='f418' name='AnyOtherBenifit' value='1' tabindex=40 title="Are you entitled to any other benefit occasioned by your disability from your Employer? - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f419_box'></div><p /><label for='f419' class='clslbl'>Are you entitled to any other benefit occasioned by your disability from your Employer? - 2</label>
<input type=RADIO class='f419' id='f419' name='AnyOtherBenifit' value='2' tabindex=40 title="Are you entitled to any other benefit occasioned by your disability from your Employer? - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<p /><label for='f420' class='clslbl'> Amount from Employer</label>
<textarea class='f420' id='f420' name='OtherPolicy_Employer' spellcheck='false' tabindex=41 title=" Amount from Employer" onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text37'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text38'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text46'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>R <br /></span></div>
<div class='div_text34'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Your employer <br /></span></div>
<div class='div_text43'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Amount <br /></span></div>
<div class='f434_box'></div><p /><label for='f434' class='clslbl'>Are you entitled to any other benefit occasioned by your disability from The state? - 1</label>
<input type=RADIO class='f434' id='f434' name='AnyOtherBenifit_2' value='1' tabindex=42 title="Are you entitled to any other benefit occasioned by your disability from The state? - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f435_box'></div><p /><label for='f435' class='clslbl'>Are you entitled to any other benefit occasioned by your disability from The state? - 2</label>
<input type=RADIO class='f435' id='f435' name='AnyOtherBenifit_2' value='2' tabindex=42 title="Are you entitled to any other benefit occasioned by your disability from The state? - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<p /><label for='f436' class='clslbl'> Amount From the State</label>
<textarea class='f436' id='f436' name='OtherPolicy_State' spellcheck='false' tabindex=43 title=" Amount From the State" onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text39'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text40'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text47'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>R <br /></span></div>
<div class='div_text35'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>The state <br /></span></div>
<div class='div_text44'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Amount <br /></span></div>
<div class='div_text36'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Other <br /></span></div>
<div class='f447_box'></div><p /><label for='f447' class='clslbl'>Are you entitled to any other benefit occasioned by your disability from, any other? - 1</label>
<input type=RADIO class='f447' id='f447' name='AnyOtherBenifit_3' value='1' tabindex=44 title="Are you entitled to any other benefit occasioned by your disability from, any other? - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f448_box'></div><p /><label for='f448' class='clslbl'>Are you entitled to any other benefit occasioned by your disability from, any other? - 2</label>
<input type=RADIO class='f448' id='f448' name='AnyOtherBenifit_3' value='2' tabindex=44 title="Are you entitled to any other benefit occasioned by your disability from, any other? - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<p /><label for='f449' class='clslbl'> Amount Other</label>
<textarea class='f449' id='f449' name='OtherPolicy_Other' spellcheck='false' tabindex=45 title=" Amount Other" onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text41'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text42'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text48'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>R <br /></span></div>
<div class='div_text45'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Amount <br /></span></div>
<div class='div_text54'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>1.3 <br /></span></div>
<p /><label for='f472' class='clslbl'>What was your main occupation at the time of commencement of disability?</label>
<textarea class='f472' id='f472' name='Occ' spellcheck='false' tabindex=46 title="What was your main occupation at the time of commencement of disability?" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 1);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text49'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>1.3.1 What was your main occupation at the time of commencement of the disability? <br /></span></div>
<div class='div_text50'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>1.3.2 Please describe your duties fully: <br /></span></div>
<p /><label for='f486' class='clslbl'>Please describe your Duties</label>
<textarea class='f486' id='f486' name='Duty_Description' spellcheck='false' tabindex=47 title="Please describe your Duties" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,100);' onKeyDown = 'maxl(this,100);return EP_OKD(this,event);' ></textarea>
<div class='div_text25'><span style='font: 6pt "Arial";color:#000000;text-decoration:none;'>(*community of property) <br /></span></div>
<div class='div_line_579'></div>
<div class='div_text52'><div align='left'><span style='font: normal normal 7pt Arial;color:#000000;text-decoration: none'>Nedgroup Life Assurance Company Limited .Reg No 1993/001022/06 <br /></span></div><div align='left'><span style=''>1st Floor, Ridgeside Campus, 2 Ncondo Drive, Umhlanga Rocks, 4320; PO Box 149175, East End, 4018. <br /></span></div><div align='left'><span style=''>Tel 0860 263 543 Fax 0860 065 437 Website www.nedgrouplife.co.za. <br /></span></div></div>
<div class='div_line_589'></div>
<div class='div_text56'><div align='left'><span style='font: normal normal 7pt Arial;color:#000000;text-decoration: none'>We support resolution for unresolved disputes via the Ombudsman for Long-term insurance. We are an authorised financial services provider (licence number 40915). <br /></span></div><div align='left'><span style=''>We are a registered credit provider in terms of the National Credit Act (NCR Reg No NCRCP61) . <br /></span></div></div>
<div class='div_line_591'></div>
<div class='div_text51'><span style='font: 7pt "Arial";color:#000000;text-decoration:none;'>Page 1 of 5 <br /></span></div>
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<div class='div_text61'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>1.4&nbsp;&nbsp; What is the main focus of your work? (If a combination, indicate an estimated % split) <br /></span></div>
<div class='f60_box'></div><p /><label for='f60' class='clslbl'>What is the main focus of your work? (If a combination, indicate an estimated % split) - 1</label>
<input type=RADIO class='f60' id='f60' name='MainFocus_1' value='1' tabindex=48 title="What is the main focus of your work? (If a combination, indicate an estimated % split) - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f61_box'></div><p /><label for='f61' class='clslbl'>What is the main focus of your work? (If a combination, indicate an estimated % split) - 2</label>
<input type=RADIO class='f61' id='f61' name='MainFocus_1' value='2' tabindex=48 title="What is the main focus of your work? (If a combination, indicate an estimated % split) - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<p /><label for='f62' class='clslbl'>MainFocus_1_Split</label>
<textarea class='f62' id='f62' name='MainFocus_1_Split' spellcheck='false' tabindex=49 title="MainFocus_1_Split" onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 1);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text65'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text66'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text71'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>% split <br /></span></div>
<div class='div_text62'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Handling objects/tools; operating machines <br /></span></div>
<div class='f76_box'></div><p /><label for='f76' class='clslbl'>What is the main focus of your work? (If a combination, indicate an estimated % split) - 1</label>
<input type=RADIO class='f76' id='f76' name='MainFocus_2' value='1' tabindex=50 title="What is the main focus of your work? (If a combination, indicate an estimated % split) - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f78_box'></div><p /><label for='f78' class='clslbl'>What is the main focus of your work? (If a combination, indicate an estimated % split) - 2</label>
<input type=RADIO class='f78' id='f78' name='MainFocus_2' value='2' tabindex=50 title="What is the main focus of your work? (If a combination, indicate an estimated % split) - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<p /><label for='f80' class='clslbl'>MainFocus_2_Split</label>
<textarea class='f80' id='f80' name='MainFocus_2_Split' spellcheck='false' tabindex=51 title="MainFocus_2_Split" onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 1);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text67'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text68'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text72'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>% split <br /></span></div>
<div class='div_text63'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Interacting with people <br /></span></div>
<div class='f112_box'></div><p /><label for='f112' class='clslbl'>What is the main focus of your work? (If a combination, indicate an estimated % split) - 1</label>
<input type=RADIO class='f112' id='f112' name='MainFocus_3' value='1' tabindex=52 title="What is the main focus of your work? (If a combination, indicate an estimated % split) - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f113_box'></div><p /><label for='f113' class='clslbl'>What is the main focus of your work? (If a combination, indicate an estimated % split) - 2</label>
<input type=RADIO class='f113' id='f113' name='MainFocus_3' value='2' tabindex=52 title="What is the main focus of your work? (If a combination, indicate an estimated % split) - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<p /><label for='f114' class='clslbl'>MainFocus_3_Split</label>
<textarea class='f114' id='f114' name='MainFocus_3_Split' spellcheck='false' tabindex=53 title="MainFocus_3_Split" onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 1);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text69'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text70'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text73'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>% split <br /></span></div>
<div class='div_text64'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Processing information (eg accounting) <br /></span></div>
<div class='f133_box'></div><p /><label for='f133' class='clslbl'>What is the main focus of your work? (If a combination, indicate an estimated % split) - 1</label>
<input type=RADIO class='f133' id='f133' name='MainFocus_4' value='1' tabindex=54 title="What is the main focus of your work? (If a combination, indicate an estimated % split) - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f135_box'></div><p /><label for='f135' class='clslbl'>What is the main focus of your work? (If a combination, indicate an estimated % split) - 2</label>
<input type=RADIO class='f135' id='f135' name='MainFocus_4' value='2' tabindex=54 title="What is the main focus of your work? (If a combination, indicate an estimated % split) - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<p /><label for='f136' class='clslbl'>MainFocus_4_Split</label>
<textarea class='f136' id='f136' name='MainFocus_4_Split' spellcheck='false' tabindex=55 title="MainFocus_4_Split" onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 1);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text75'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text76'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text77'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>% split <br /></span></div>
<div class='div_text74'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Travel <br /></span></div>
<p /><label for='f147' class='clslbl'>Other Occupations</label>
<textarea class='f147' id='f147' name='Other_Occupations' spellcheck='false' tabindex=56 title="Other Occupations" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 1);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text78'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>1.5&nbsp;&nbsp;Other occupation(s), if any <br /></span></div>
<div class='div_text79'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>1.6&nbsp;&nbsp; Name and address of employer at the time of the disablement: <br /></span></div>
<p /><label for='f169' class='clslbl'>1.6   Name of employer at the time of the disablement:</label>
<textarea class='f169' id='f169' name='Emp_TimeOfDisability' spellcheck='false' tabindex=57 title="1.6&nbsp;&nbsp; Name of employer at the time of the disablement:" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f181' class='clslbl'>Address of employer at the time of the disablement</label>
<input type=TEXT value='' class='f181' id='f181' name='Address_EmpTOD_Line1' tabindex=58 title="Address of employer at the time of the disablement" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text80'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Line 1 <br /></span></div>
<p /><label for='f191' class='clslbl'>Address of employer at the time of the disablement</label>
<input type=TEXT value='' class='f191' id='f191' name='Address_EmpTOD_Line2' tabindex=59 title="Address of employer at the time of the disablement" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text81'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Line 2 <br /></span></div>
<p /><label for='f199' class='clslbl'>Address of employer at the time of the disablement</label>
<input type=TEXT value='' class='f199' id='f199' name='Address_EmpTOD_Suburb' tabindex=60 title="Address of employer at the time of the disablement" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 1);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text82'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Suburb <br /></span></div>
<p /><label for='f214' class='clslbl'>Address of employer at the time of the disablement</label>
<input type=TEXT value='' class='f214' id='f214' name='Address_EmpTOD_Town' tabindex=61 title="Address of employer at the time of the disablement" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text83'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Town <br /></span></div>
<p /><label for='f222' class='clslbl'>Address of employer at the time of the disablement</label>
<input type=TEXT value='' class='f222' id='f222' name='Address_EmpTOD_Code' tabindex=62 title="Address of employer at the time of the disablement" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text84'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Code <br /></span></div>
<p /><label for='f255' class='clslbl'>What was your total taxable income in the 12 months preceding your disablement?</label>
<textarea class='f255' id='f255' name='TotalTaxableIncome_Prior' spellcheck='false' tabindex=63 title="What was your total taxable income in the 12 months preceding your disablement?" onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text85'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>R <br /></span></div>
<div class='div_text86'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>1.8 What was your total taxable income in the 12 months preceding your disablement? <br /></span></div>
<div class='div_text111'><div align='left'><span style='font: bold normal 8pt Arial;color:#000000;text-decoration: none'>NB: Deduct allowable expenses incurred in the production of your income. <br /></span></div><div align='left'><span style=''>Do not deduct any pension fund or retirement annuity fund contributions or medical expenses. <br /></span></div></div>
<div class='div_text87'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>1.9 Skills training (on the job): <br /></span></div>
<p /><label for='f303' class='clslbl'>Skills training (on the job):</label>
<textarea class='f303' id='f303' name='Skills_Training' spellcheck='false' tabindex=64 title="Skills training (on the job):" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,100);' onKeyDown = 'maxl(this,100);return EP_OKD(this,event);' ></textarea>
<div class='div_text88'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>1.10&nbsp;&nbsp;What school grade, academic, professional or trade qualifications do you possess? <br /></span></div>
<p /><label for='f334' class='clslbl'>What school grade, academic, professional or trade qualifications do you possess?</label>
<textarea class='f334' id='f334' name='Qualifications' spellcheck='false' tabindex=65 title="What school grade, academic, professional or trade qualifications do you possess?" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text89'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>2 MEDICAL HISTORY <br /></span></div>
<div class='div_text90'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>2.1 General <br /></span></div>
<div class='div_text91'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>2.1.1 Which injury or illness has given rise to this claim? <br /></span></div>
<p /><label for='f417' class='clslbl'>Which injury or illness has given rise to this claim?</label>
<textarea class='f417' id='f417' name='WhichIllness' spellcheck='false' tabindex=66 title="Which injury or illness has given rise to this claim?" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f445' class='clslbl'>When did you first consult a medical practitioner in connection with this condition?</label>
<input type=TEXT value='' class='f445' id='f445' name='Consult_Doc_Date' tabindex=67 title="When did you first consult a medical practitioner in connection with this condition?" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text112'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<div class='div_text92'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>2.1.2 When did you first consult a medical practitioner in connection with this condition? <br /></span></div>
<div class='div_text93'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>2.1.3 Have you had any similar or related illness or injury in the past? <br /></span></div>
<div class='f464_box'></div><p /><label for='f464' class='clslbl'>Have you had any similar or related illness or injury in the past? - 1</label>
<input type=RADIO class='f464' id='f464' name='Similar_1' value='1' tabindex=68 title="Have you had any similar or related illness or injury in the past? - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f465_box'></div><p /><label for='f465' class='clslbl'>Have you had any similar or related illness or injury in the past? - 2</label>
<input type=RADIO class='f465' id='f465' name='Similar_1' value='2' tabindex=68 title="Have you had any similar or related illness or injury in the past? - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text94'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text95'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text96'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>If yes, give details: <br /></span></div>
<p /><label for='f483' class='clslbl'> If yes, give details of similar past injuries</label>
<textarea class='f483' id='f483' name='Similar_1_Details' spellcheck='false' tabindex=69 title=" If yes, give details of similar past injuries" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text97'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>2.1.4 Have you had any other illness or injury in the past? <br /></span></div>
<div class='f494_box'></div><p /><label for='f494' class='clslbl'>Have you had any other illness or injury in the past? - 1</label>
<input type=RADIO class='f494' id='f494' name='Similar_2' value='1' tabindex=70 title="Have you had any other illness or injury in the past? - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f495_box'></div><p /><label for='f495' class='clslbl'>Have you had any other illness or injury in the past? - 2</label>
<input type=RADIO class='f495' id='f495' name='Similar_2' value='2' tabindex=70 title="Have you had any other illness or injury in the past? - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text98'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text99'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text100'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>If yes, give details: <br /></span></div>
<p /><label for='f513' class='clslbl'> If yes, give details of any past injuries</label>
<textarea class='f513' id='f513' name='Similar_2_Details' spellcheck='false' tabindex=71 title=" If yes, give details of any past injuries" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,100);' onKeyDown = 'maxl(this,100);return EP_OKD(this,event);' ></textarea>
<div class='div_text101'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>2.2 Specific: Complete the applicable subsection(s) only. <br /></span></div>
<div class='div_text102'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>2.2.1 If your health status has been changed by an illness, when was it first diagnosed? <br /></span></div>
<p /><label for='f538' class='clslbl'>If your health status has been changed by an illness, when was it first diagnosed?</label>
<input type=TEXT value='' class='f538' id='f538' name='Date_of_event' tabindex=72 title="If your health status has been changed by an illness, when was it first diagnosed?" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text113'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<div class='f555_box'></div><p /><label for='f555' class='clslbl'>How has it been treated? - 1</label>
<input type=RADIO class='f555' id='f555' name='treatment' value='1' tabindex=73 title="How has it been treated? - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f556_box'></div><p /><label for='f556' class='clslbl'>How has it been treated? - 2</label>
<input type=RADIO class='f556' id='f556' name='treatment' value='2' tabindex=73 title="How has it been treated? - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f557_box'></div><p /><label for='f557' class='clslbl'>How has it been treated? - 3</label>
<input type=RADIO class='f557' id='f557' name='treatment' value='3' tabindex=73 title="How has it been treated? - 3" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f558_box'></div><p /><label for='f558' class='clslbl'>How has it been treated? - 4</label>
<input type=RADIO class='f558' id='f558' name='treatment' value='4' tabindex=73 title="How has it been treated? - 4" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text107'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>How has it been treated? <br /></span></div>
<div class='div_text103'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Medication <br /></span></div>
<div class='div_text104'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Exercise <br /></span></div>
<div class='div_text105'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Operations <br /></span></div>
<div class='div_text106'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Other <br /></span></div>
<div class='div_text108'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>If other, specify: <br /></span></div>
<p /><label for='f576' class='clslbl'> If other, specify treatment</label>
<textarea class='f576' id='f576' name='Treatment_Details' spellcheck='false' tabindex=74 title=" If other, specify treatment" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,100);' onKeyDown = 'maxl(this,100);return EP_OKD(this,event);' ></textarea>
<div class='div_line_581'></div>
<div class='div_text110'><div align='left'><span style='font: normal normal 7pt Arial;color:#000000;text-decoration: none'>Nedgroup Life Assurance Company Limited .Reg No 1993/001022/06 <br /></span></div><div align='left'><span style=''>1st Floor, Ridgeside Campus, 2 Ncondo Drive, Umhlanga Rocks, 4320; PO Box 149175, East End, 4018. <br /></span></div><div align='left'><span style=''>Tel 0860 263 543 Fax 0860 065 437 Website www.nedgrouplife.co.za. <br /></span></div></div>
<div class='div_line_592'></div>
<div class='div_text109'><span style='font: 7pt "Arial";color:#000000;text-decoration:none;'>Page 2 of 5 <br /></span></div>
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<div class='div_text114'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>2.2.2 If your health status has been changed by an injury, provide the date of the injury <br /></span></div>
<p /><label for='f46' class='clslbl'>If your health status has been changed by an injury, provide the date of the injury</label>
<input type=TEXT value='' class='f46' id='f46' name='Date_Of_Injury' tabindex=75 title="If your health status has been changed by an injury, provide the date of the injury" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text163'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<p /><label for='f59' class='clslbl'>Cause of injury</label>
<textarea class='f59' id='f59' name='Cause_Of_Injury' spellcheck='false' tabindex=76 title="Cause of injury" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text122'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Cause of injury <br /></span></div>
<div class='f77_box'></div><p /><label for='f77' class='clslbl'>How has it been treated? - 1</label>
<input type=RADIO class='f77' id='f77' name='treatment_2' value='1' tabindex=77 title="How has it been treated? - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f79_box'></div><p /><label for='f79' class='clslbl'>How has it been treated? - 2</label>
<input type=RADIO class='f79' id='f79' name='treatment_2' value='2' tabindex=77 title="How has it been treated? - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f81_box'></div><p /><label for='f81' class='clslbl'>How has it been treated? - 3</label>
<input type=RADIO class='f81' id='f81' name='treatment_2' value='3' tabindex=77 title="How has it been treated? - 3" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f82_box'></div><p /><label for='f82' class='clslbl'>How has it been treated? - 4</label>
<input type=RADIO class='f82' id='f82' name='treatment_2' value='4' tabindex=77 title="How has it been treated? - 4" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text124'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Medication <br /></span></div>
<div class='div_text125'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Exercise <br /></span></div>
<div class='div_text126'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Operations <br /></span></div>
<div class='div_text127'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Other <br /></span></div>
<div class='div_text123'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>How has it been treated? <br /></span></div>
<div class='div_text115'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>If other, specify: <br /></span></div>
<p /><label for='f130' class='clslbl'> Specify Other Treatment</label>
<textarea class='f130' id='f130' name='Injury_Treatment' spellcheck='false' tabindex=78 title=" Specify Other Treatment" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,100);' onKeyDown = 'maxl(this,100);return EP_OKD(this,event);' ></textarea>
<div class='div_text116'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>2.2.3 If the illness/injury has been caused by an accident or violent means, was it: <br /></span></div>
<div class='f160_box'></div><p /><label for='f160' class='clslbl'>If the illness/injury has been caused by an accident or violent means, was it - 1</label>
<input type=RADIO class='f160' id='f160' name='Cause_Of_Injury_2' value='1' tabindex=79 title="If the illness/injury has been caused by an accident or violent means, was it - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f161_box'></div><p /><label for='f161' class='clslbl'>If the illness/injury has been caused by an accident or violent means, was it - 2</label>
<input type=RADIO class='f161' id='f161' name='Cause_Of_Injury_2' value='2' tabindex=79 title="If the illness/injury has been caused by an accident or violent means, was it - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f162_box'></div><p /><label for='f162' class='clslbl'>If the illness/injury has been caused by an accident or violent means, was it - 3</label>
<input type=RADIO class='f162' id='f162' name='Cause_Of_Injury_2' value='3' tabindex=79 title="If the illness/injury has been caused by an accident or violent means, was it - 3" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f163_box'></div><p /><label for='f163' class='clslbl'>If the illness/injury has been caused by an accident or violent means, was it - 4</label>
<input type=RADIO class='f163' id='f163' name='Cause_Of_Injury_2' value='4' tabindex=79 title="If the illness/injury has been caused by an accident or violent means, was it - 4" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text117'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Motor vehicle accident, <br /></span></div>
<div class='div_text118'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>an accident at work, <br /></span></div>
<div class='div_text119'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>an accident at home or <br /></span></div>
<div class='div_text120'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>other? <br /></span></div>
<div class='div_text128'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>If other, specify: <br /></span></div>
<p /><label for='f188' class='clslbl'> Specify Other cause of accident</label>
<textarea class='f188' id='f188' name='Cause_Of_Injury_Details' spellcheck='false' tabindex=80 title=" Specify Other cause of accident" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,100);' onKeyDown = 'maxl(this,100);return EP_OKD(this,event);' ></textarea>
<div class='f204_box'></div><p /><label for='f204' class='clslbl'>Was there an official enquiry? - 1</label>
<input type=RADIO class='f204' id='f204' name='Official_Enquiry' value='1' tabindex=81 title="Was there an official enquiry? - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f205_box'></div><p /><label for='f205' class='clslbl'>Was there an official enquiry? - 2</label>
<input type=RADIO class='f205' id='f205' name='Official_Enquiry' value='2' tabindex=81 title="Was there an official enquiry? - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<p /><label for='f206' class='clslbl'>When did the accident occur?</label>
<input type=TEXT value='' class='f206' id='f206' name='Date_of_Accident' tabindex=82 title="When did the accident occur?" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text132'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text133'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text130'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>When did it occur? <br /></span></div>
<div class='div_text131'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Was there an official enquiry? <br /></span></div>
<div class='div_text164'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<div class='div_text121'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>If YES, by whom? <br /></span></div>
<p /><label for='f225' class='clslbl'> If YES, by whom?</label>
<textarea class='f225' id='f225' name='Official_Enquiry_Details' spellcheck='false' tabindex=83 title=" If YES, by whom?" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,100);' onKeyDown = 'maxl(this,100);return EP_OKD(this,event);' ></textarea>
<div class='f247_box'></div><p /><label for='f247' class='clslbl'>Has any legal action been taken? - 1</label>
<input type=RADIO class='f247' id='f247' name='AnyLegalAction' value='1' tabindex=84 title="Has any legal action been taken? - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f248_box'></div><p /><label for='f248' class='clslbl'>Has any legal action been taken? - 2</label>
<input type=RADIO class='f248' id='f248' name='AnyLegalAction' value='2' tabindex=84 title="Has any legal action been taken? - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text134'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text135'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text129'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>2.2.4 Has any legal action been taken? <br /></span></div>
<div class='div_text136'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>If YES, by whom? <br /></span></div>
<p /><label for='f282' class='clslbl'> If YES, by whom?</label>
<textarea class='f282' id='f282' name='AnyLegalAction_Details' spellcheck='false' tabindex=85 title=" If YES, by whom?" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f299' class='clslbl'>If appropriate, give the: Police station</label>
<textarea class='f299' id='f299' name='LegalAction_Police_Station' spellcheck='false' tabindex=86 title="If appropriate, give the: Police station" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f300' class='clslbl'>Case Number</label>
<textarea class='f300' id='f300' name='LegalAction_Police_Number' spellcheck='false' tabindex=87 title="Case Number" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text137'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>If appropriate, give the: Police station <br /></span></div>
<div class='div_text138'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Police case number <br /></span></div>
<div class='div_text139'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>SECTION 3 - HOSPITALISATION FOR SPECIAL INVESTIGATIONS OR TREATMENT <br /></span></div>
<div class='div_text140'>   <span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Repeat the information for </span><span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>every  </span><span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>period in hospital. <br /></span></div>
<div class='div_rect_329'></div>
<div class='div_line_331'></div>
<div class='div_line_332'></div>
<div class='div_line_333'></div>
<div class='div_text141'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>Name of hospital <br /></span></div>
<div class='div_text142'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>Date of admission <br /></span></div>
<div class='div_text143'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>Date of discharge <br /></span></div>
<div class='div_text144'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>Purpose <br /></span></div>
<div class='div_text165'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<div class='div_text166'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<div class='div_line_355'></div>
<p /><label for='f356' class='clslbl'>Hospital name 1</label>
<textarea class='f356' id='f356' name='Hospital_Name_1' spellcheck='false' tabindex=88 title="Hospital name 1" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f357' class='clslbl'>Cell number</label>
<input type=TEXT value='' class='f357' id='f357' name='Date_of_Adminssion_1' tabindex=89 title="Cell number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<p /><label for='f358' class='clslbl'>Cell number</label>
<input type=TEXT value='' class='f358' id='f358' name='Date_of_Discharge_1' tabindex=90 title="Cell number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<p /><label for='f359' class='clslbl'>Purpose_1</label>
<textarea class='f359' id='f359' name='Purpose_1' spellcheck='false' tabindex=91 title="Purpose_1" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f370' class='clslbl'>Hospital name 2</label>
<textarea class='f370' id='f370' name='Hospital_Name_2' spellcheck='false' tabindex=92 title="Hospital name 2" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f371' class='clslbl'>Cell number</label>
<input type=TEXT value='' class='f371' id='f371' name='Date_of_Adminssion_2' tabindex=93 title="Cell number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<p /><label for='f372' class='clslbl'>Cell number</label>
<input type=TEXT value='' class='f372' id='f372' name='Date_of_Discharge_2' tabindex=94 title="Cell number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<p /><label for='f373' class='clslbl'>Purpose_2</label>
<textarea class='f373' id='f373' name='Purpose_2' spellcheck='false' tabindex=95 title="Purpose_2" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f385' class='clslbl'>Hospital name 3</label>
<textarea class='f385' id='f385' name='Hospital_Name_3' spellcheck='false' tabindex=96 title="Hospital name 3" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f386' class='clslbl'>Cell number</label>
<input type=TEXT value='' class='f386' id='f386' name='Date_of_Adminssion_3' tabindex=97 title="Cell number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<p /><label for='f387' class='clslbl'>Cell number</label>
<input type=TEXT value='' class='f387' id='f387' name='Date_of_Discharge_3' tabindex=98 title="Cell number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<p /><label for='f388' class='clslbl'>Purpose_3</label>
<textarea class='f388' id='f388' name='Purpose_3' spellcheck='false' tabindex=99 title="Purpose_3" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f400' class='clslbl'>Cell number</label>
<input type=TEXT value='' class='f400' id='f400' name='Date_of_Discharge_4' tabindex=102 title="Cell number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<p /><label for='f401' class='clslbl'>Hospital name 4</label>
<textarea class='f401' id='f401' name='Hospital_Name_4' spellcheck='false' tabindex=100 title="Hospital name 4" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f402' class='clslbl'>Cell number</label>
<input type=TEXT value='' class='f402' id='f402' name='Date_of_Adminssion_4' tabindex=101 title="Cell number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<p /><label for='f403' class='clslbl'>Purpose_4</label>
<textarea class='f403' id='f403' name='Purpose_4' spellcheck='false' tabindex=103 title="Purpose_4" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<div class='div_text145'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>SECTION 4 - PRIVATE HEALTH SECTOR <br /></span></div>
<p /><label for='f432' class='clslbl'>Name of current general practitioner</label>
<textarea class='f432' id='f432' name='Name_of_GP' spellcheck='false' tabindex=104 title="Name of current general practitioner" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<div class='div_text146'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>4.1 Name of current general practitioner <br /></span></div>
<div class='div_text147'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>4.2 Please state postal address <br /></span></div>
<p /><label for='f452' class='clslbl'>Postal Address of current general practitioner</label>
<input type=TEXT value='' class='f452' id='f452' name='GP_Address_Line1' tabindex=105 title="Postal Address of current general practitioner" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text148'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Line 1 <br /></span></div>
<p /><label for='f460' class='clslbl'>Postal Address of current general practitioner</label>
<input type=TEXT value='' class='f460' id='f460' name='GP_Address_Line2' tabindex=106 title="Postal Address of current general practitioner" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text149'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Line 2 <br /></span></div>
<p /><label for='f475' class='clslbl'>Postal Address of current general practitioner</label>
<input type=TEXT value='' class='f475' id='f475' name='GP_Address_Suburb' tabindex=107 title="Postal Address of current general practitioner" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 1);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text150'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Suburb <br /></span></div>
<p /><label for='f484' class='clslbl'>Postal Address of current general practitioner</label>
<input type=TEXT value='' class='f484' id='f484' name='GP_Address_Town' tabindex=108 title="Postal Address of current general practitioner" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 1);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text151'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Town <br /></span></div>
<p /><label for='f488' class='clslbl'>Postal Code of current general practitioner</label>
<input type=TEXT value='' class='f488' id='f488' name='GP_Address_Code' tabindex=109 title="Postal Code of current general practitioner" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<p /><label for='f490' class='clslbl'>Telephone Number of current general practitioner</label>
<input type=TEXT value='' class='f490' id='f490' name='GPTelWork' tabindex=110 title="Telephone Number of current general practitioner" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<div class='div_text152'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Code <br /></span></div>
<div class='div_text153'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Telephone no (practice) <br /></span></div>
<p /><label for='f503' class='clslbl'>Period of Cunsultation from</label>
<input type=TEXT value='' class='f503' id='f503' name='ConsultationPeriodFrom' tabindex=111 title="Period of Cunsultation from" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<p /><label for='f505' class='clslbl'>Period of Cunsultation to</label>
<input type=TEXT value='' class='f505' id='f505' name='ConsultationPeriodTo' tabindex=112 title="Period of Cunsultation to" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text167'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<div class='div_text168'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<div class='div_text159'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Period of consultation <br /></span></div>
<div class='div_text160'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>to <br /></span></div>
<div class='div_text154'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>4.3 Name(s) of attending specialist(s) <br /></span></div>
<div class='div_rect_518'></div>
<div class='div_line_519'></div>
<div class='div_line_520'></div>
<div class='div_line_521'></div>
<div class='div_text155'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>Name <br /></span></div>
<div class='div_text156'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>Type of specialist <br /></span></div>
<div class='div_text157'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>Telephone number <br /></span></div>
<div class='div_text158'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>Period of consultation <br /></span></div>
<div class='div_line_530'></div>
<p /><label for='f531' class='clslbl'>Name(s) of attending specialist(s)</label>
<textarea class='f531' id='f531' name='Specialist_Name_1' spellcheck='false' tabindex=113 title="Name(s) of attending specialist(s)" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f534' class='clslbl'>Type of attending specialist(s)</label>
<textarea class='f534' id='f534' name='Specialist_Type_1' spellcheck='false' tabindex=114 title="Type of attending specialist(s)" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f535' class='clslbl'>Telephone Number of attending specialist(s)</label>
<input type=TEXT value='' class='f535' id='f535' name='Specialist_TelNo_1' tabindex=115 title="Telephone Number of attending specialist(s)" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<p /><label for='f536' class='clslbl'>Period of attending specialist(s)</label>
<textarea class='f536' id='f536' name='Specialist_ConsultPeriod_1' spellcheck='false' tabindex=116 title="Period of attending specialist(s)" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f539' class='clslbl'>Name(s) of attending specialist(s)</label>
<textarea class='f539' id='f539' name='Specialist_Name_2' spellcheck='false' tabindex=117 title="Name(s) of attending specialist(s)" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f540' class='clslbl'>Type of attending specialist(s)</label>
<textarea class='f540' id='f540' name='Specialist_Type_2' spellcheck='false' tabindex=118 title="Type of attending specialist(s)" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f541' class='clslbl'>Telephone Number of attending specialist(s)</label>
<input type=TEXT value='' class='f541' id='f541' name='Specialist_TelNo_2' tabindex=119 title="Telephone Number of attending specialist(s)" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<p /><label for='f542' class='clslbl'>Period of attending specialist(s)</label>
<textarea class='f542' id='f542' name='Specialist_ConsultPeriod_2' spellcheck='false' tabindex=120 title="Period of attending specialist(s)" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f551' class='clslbl'>Name(s) of attending specialist(s)</label>
<textarea class='f551' id='f551' name='Specialist_Name_3' spellcheck='false' tabindex=121 title="Name(s) of attending specialist(s)" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f552' class='clslbl'>Type of attending specialist(s)</label>
<textarea class='f552' id='f552' name='Specialist_Type_3' spellcheck='false' tabindex=122 title="Type of attending specialist(s)" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f553' class='clslbl'>Telephone Number of attending specialist(s)</label>
<input type=TEXT value='' class='f553' id='f553' name='Specialist_TelNo_3' tabindex=123 title="Telephone Number of attending specialist(s)" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<p /><label for='f554' class='clslbl'>Period of attending specialist(s)</label>
<textarea class='f554' id='f554' name='Specialist_ConsultPeriod_3' spellcheck='false' tabindex=124 title="Period of attending specialist(s)" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f566' class='clslbl'>Name(s) of attending specialist(s)</label>
<textarea class='f566' id='f566' name='Specialist_Name_4' spellcheck='false' tabindex=125 title="Name(s) of attending specialist(s)" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f567' class='clslbl'>Type of attending specialist(s)</label>
<textarea class='f567' id='f567' name='Specialist_Type_4' spellcheck='false' tabindex=126 title="Type of attending specialist(s)" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f568' class='clslbl'>Telephone Number of attending specialist(s)</label>
<input type=TEXT value='' class='f568' id='f568' name='Specialist_TelNo_4' tabindex=127 title="Telephone Number of attending specialist(s)" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<p /><label for='f569' class='clslbl'>Period of attending specialist(s)</label>
<textarea class='f569' id='f569' name='Specialist_ConsultPeriod_4' spellcheck='false' tabindex=128 title="Period of attending specialist(s)" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<div class='div_line_582'></div>
<div class='div_text162'><div align='left'><span style='font: normal normal 7pt Arial;color:#000000;text-decoration: none'>Nedgroup Life Assurance Company Limited .Reg No 1993/001022/06 <br /></span></div><div align='left'><span style=''>1st Floor, Ridgeside Campus, 2 Ncondo Drive, Umhlanga Rocks, 4320; PO Box 149175, East End, 4018. <br /></span></div><div align='left'><span style=''>Tel 0860 263 543 Fax 0860 065 437 Website www.nedgrouplife.co.za. <br /></span></div></div>
<div class='div_line_593'></div>
<div class='div_text161'><span style='font: 7pt "Arial";color:#000000;text-decoration:none;'>Page 3 of 5 <br /></span></div>
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<div class='div_line_40'></div>
<div class='div_text169'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>4.4 Name(s) of other health professional(s)/therapist(s) consulted <br /></span></div>
<div class='div_rect_49'></div>
<div class='div_line_50'></div>
<div class='div_line_51'></div>
<div class='div_line_53'></div>
<div class='div_text170'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>Name <br /></span></div>
<div class='div_text171'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>Type of professional <br /></span></div>
<div class='div_text172'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>Telephone number <br /></span></div>
<div class='div_text173'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>Period of consultation <br /></span></div>
<div class='div_line_70'></div>
<p /><label for='f71' class='clslbl'>Name(s) of other health professional(s)/therapist(s) consulted</label>
<textarea class='f71' id='f71' name='HealthPro_Name_1' spellcheck='false' tabindex=129 title="Name(s) of other health professional(s)/therapist(s) consulted" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f72' class='clslbl'>Type of other health professional(s)/therapist(s) consulted</label>
<textarea class='f72' id='f72' name='HealthPro_Type_1' spellcheck='false' tabindex=130 title="Type of other health professional(s)/therapist(s) consulted" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f73' class='clslbl'>Tel of other health professional(s)/therapist(s) consulted</label>
<input type=TEXT value='' class='f73' id='f73' name='HealthPro_Tel_1' tabindex=131 title="Tel of other health professional(s)/therapist(s) consulted" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<p /><label for='f74' class='clslbl'>HealthPro_ConsultPeriod_1</label>
<textarea class='f74' id='f74' name='HealthPro_ConsultPeriod_1' spellcheck='false' tabindex=132 title="HealthPro_ConsultPeriod_1" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 1);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f102' class='clslbl'>Name(s) of other health professional(s)/therapist(s) consulted</label>
<textarea class='f102' id='f102' name='HealthPro_Name_2' spellcheck='false' tabindex=133 title="Name(s) of other health professional(s)/therapist(s) consulted" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f103' class='clslbl'>Type of other health professional(s)/therapist(s) consulted</label>
<textarea class='f103' id='f103' name='HealthPro_Type_2' spellcheck='false' tabindex=134 title="Type of other health professional(s)/therapist(s) consulted" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f104' class='clslbl'>Tel of other health professional(s)/therapist(s) consulted</label>
<input type=TEXT value='' class='f104' id='f104' name='HealthPro_Tel_2' tabindex=135 title="Tel of other health professional(s)/therapist(s) consulted" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<p /><label for='f105' class='clslbl'>HealthPro_ConsultPeriod_2</label>
<textarea class='f105' id='f105' name='HealthPro_ConsultPeriod_2' spellcheck='false' tabindex=136 title="HealthPro_ConsultPeriod_2" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 1);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f118' class='clslbl'>Name(s) of other health professional(s)/therapist(s) consulted</label>
<textarea class='f118' id='f118' name='HealthPro_Name_3' spellcheck='false' tabindex=137 title="Name(s) of other health professional(s)/therapist(s) consulted" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f120' class='clslbl'>Type of other health professional(s)/therapist(s) consulted</label>
<textarea class='f120' id='f120' name='HealthPro_Type_3' spellcheck='false' tabindex=138 title="Type of other health professional(s)/therapist(s) consulted" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f121' class='clslbl'>Tel of other health professional(s)/therapist(s) consulted</label>
<input type=TEXT value='' class='f121' id='f121' name='HealthPro_Tel_3' tabindex=139 title="Tel of other health professional(s)/therapist(s) consulted" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<p /><label for='f122' class='clslbl'>HealthPro_ConsultPeriod_3</label>
<textarea class='f122' id='f122' name='HealthPro_ConsultPeriod_3' spellcheck='false' tabindex=140 title="HealthPro_ConsultPeriod_3" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 1);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f131' class='clslbl'>Name(s) of other health professional(s)/therapist(s) consulted</label>
<textarea class='f131' id='f131' name='HealthPro_Name_4' spellcheck='false' tabindex=141 title="Name(s) of other health professional(s)/therapist(s) consulted" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f132' class='clslbl'>Type of other health professional(s)/therapist(s) consulted</label>
<textarea class='f132' id='f132' name='HealthPro_Type_4' spellcheck='false' tabindex=142 title="Type of other health professional(s)/therapist(s) consulted" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f134' class='clslbl'>Tel of other health professional(s)/therapist(s) consulted</label>
<input type=TEXT value='' class='f134' id='f134' name='HealthPro_Tel_4' tabindex=143 title="Tel of other health professional(s)/therapist(s) consulted" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<p /><label for='f137' class='clslbl'>HealthPro_ConsultPeriod_4</label>
<textarea class='f137' id='f137' name='HealthPro_ConsultPeriod_4' spellcheck='false' tabindex=144 title="HealthPro_ConsultPeriod_4" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 1);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<div class='div_text174'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>SECTION 5 - PUBLIC HEALTH SECTOR <br /></span></div>
<p /><label for='f154' class='clslbl'>Public Sector Name of hospital</label>
<textarea class='f154' id='f154' name='PHS_Hosp_name' spellcheck='false' tabindex=145 title="Public Sector Name of hospital" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f155' class='clslbl'>Public Sector Reference number at hospital</label>
<textarea class='f155' id='f155' name='PHS_PatientNumber' spellcheck='false' tabindex=146 title="Public Sector Reference number at hospital" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<div class='div_text175'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>5.1 Name of hospital <br /></span></div>
<div class='div_text176'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Patient reference number <br /></span></div>
<div class='div_text177'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>5.2 Please state postal address <br /></span></div>
<p /><label for='f179' class='clslbl'>Public Sector Address of hospital</label>
<input type=TEXT value='' class='f179' id='f179' name='PHS_Hosp_Address_Line1' tabindex=147 title="Public Sector Address of hospital" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text182'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Line 1 <br /></span></div>
<p /><label for='f189' class='clslbl'>Public Sector Address of hospital</label>
<input type=TEXT value='' class='f189' id='f189' name='PHS_Hosp_Address_Line2' tabindex=148 title="Public Sector Address of hospital" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text183'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Line 2 <br /></span></div>
<p /><label for='f197' class='clslbl'>Public Sector Address of hospital</label>
<input type=TEXT value='' class='f197' id='f197' name='PHS_Hosp_Address_Suburb' tabindex=149 title="Public Sector Address of hospital" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 1);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text184'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Suburb <br /></span></div>
<p /><label for='f212' class='clslbl'>Public Sector Address of hospital</label>
<input type=TEXT value='' class='f212' id='f212' name='PHS_Hosp_Address_Town' tabindex=150 title="Public Sector Address of hospital" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text185'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Town <br /></span></div>
<p /><label for='f220' class='clslbl'>Public Sector Address of hospital</label>
<input type=TEXT value='' class='f220' id='f220' name='PHS_Hosp_Address_Code' tabindex=151 title="Public Sector Address of hospital" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text186'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Code <br /></span></div>
<p /><label for='f231' class='clslbl'>Public Sector Tel Number of hospital</label>
<input type=TEXT value='' class='f231' id='f231' name='PHS_PhoneNumber' tabindex=152 title="Public Sector Tel Number of hospital" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<p /><label for='f232' class='clslbl'>Public Sector Specialist Department</label>
<textarea class='f232' id='f232' name='PHS_Specialist_Department' spellcheck='false' tabindex=153 title="Public Sector Specialist Department" onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<div class='div_text180'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Specialist department(s) <br /></span></div>
<div class='div_text178'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>5.3 Telephone no <br /></span></div>
<p /><label for='f240' class='clslbl'>Public Sector periode of cunsultation from</label>
<input type=TEXT value='' class='f240' id='f240' name='ConsultationPeriodFrom_2' tabindex=154 title="Public Sector periode of cunsultation from" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<p /><label for='f241' class='clslbl'>Public Sector periode of cunsultation to</label>
<input type=TEXT value='' class='f241' id='f241' name='ConsultationPeriodTo_2' tabindex=155 title="Public Sector periode of cunsultation to" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text213'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<div class='div_text214'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<div class='div_text181'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>to <br /></span></div>
<div class='div_text179'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>5.4 Period of consultation <br /></span></div>
<div class='div_text187'>  <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>SECTION 6 - </span><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>  </span><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>PRACTICAL IMPLICATIONS OF YOUR HEALTH CONDITION <br /></span></div>
<div class='div_text188'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Indicate only a specific change(s) in your ability to perform the following everyday tasks, and specify which symptoms caused the change(s): <br /></span></div>
<div class='div_text189'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>6.1 Self-care, ie personal hygiene, eating, dressing, etc <br /></span></div>
<p /><label for='f293' class='clslbl'>Self-care, ie personal hygiene, eating, dressing, etc</label>
<textarea class='f293' id='f293' name='SelfCareDetails' spellcheck='false' tabindex=156 title="Self-care, ie personal hygiene, eating, dressing, etc" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,200);' onKeyDown = 'maxl(this,200);return EP_OKD(this,event);' ></textarea>
<div class='div_text190'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>6.2 Mobility, ie walking, sitting, standing, bending, carrying, etc <br /></span></div>
<p /><label for='f348' class='clslbl'>Mobility, ie walking, sitting, standing, bending, carrying, etc</label>
<textarea class='f348' id='f348' name='MobilityDetails' spellcheck='false' tabindex=157 title="Mobility, ie walking, sitting, standing, bending, carrying, etc" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,200);' onKeyDown = 'maxl(this,200);return EP_OKD(this,event);' ></textarea>
<div class='div_text191'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>6.3 Use of public or private transport <br /></span></div>
<div class='f412_box'></div><p /><label for='f412' class='clslbl'>Use of public or private transport - 1</label>
<input type=RADIO class='f412' id='f412' name='TransPortUse' value='1' tabindex=158 title="Use of public or private transport - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f413_box'></div><p /><label for='f413' class='clslbl'>Use of public or private transport - 2</label>
<input type=RADIO class='f413' id='f413' name='TransPortUse' value='2' tabindex=158 title="Use of public or private transport - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text193'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text194'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text192'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>6.4 Describe fully the nature of your disability: <br /></span></div>
<p /><label for='f442' class='clslbl'>Describe fully the nature of your disability:</label>
<textarea class='f442' id='f442' name='Nature_of_Disability' spellcheck='false' tabindex=159 title="Describe fully the nature of your disability:" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,100);' onKeyDown = 'maxl(this,100);return EP_OKD(this,event);' ></textarea>
<div class='f462_box'></div><p /><label for='f462' class='clslbl'>Is the disability permanent? - 1</label>
<input type=RADIO class='f462' id='f462' name='IsDisabilityPermanent' value='1' tabindex=160 title="Is the disability permanent? - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f463_box'></div><p /><label for='f463' class='clslbl'>Is the disability permanent? - 2</label>
<input type=RADIO class='f463' id='f463' name='IsDisabilityPermanent' value='2' tabindex=160 title="Is the disability permanent? - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text195'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text196'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text199'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Is the disability permanent? <br /></span></div>
<div class='f476_box'></div><p /><label for='f476' class='clslbl'>Are you still under treatment? - 1</label>
<input type=RADIO class='f476' id='f476' name='AreYouStillTreated' value='1' tabindex=161 title="Are you still under treatment? - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f477_box'></div><p /><label for='f477' class='clslbl'>Are you still under treatment? - 2</label>
<input type=RADIO class='f477' id='f477' name='AreYouStillTreated' value='2' tabindex=161 title="Are you still under treatment? - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text197'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text198'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text200'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>6.5 Are you still under treatment? <br /></span></div>
<div class='div_text201'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>If YES, please give the name and address of the doctor/specialist presently treating you: <br /></span></div>
<p /><label for='f489' class='clslbl'> If YES, please give the name and address of the doctor/specialist presently treating you:</label>
<textarea class='f489' id='f489' name='AreYouStillTreated_details' spellcheck='false' tabindex=162 title=" If YES, please give the name and address of the doctor/specialist presently treating you:" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,100);' onKeyDown = 'maxl(this,100);return EP_OKD(this,event);' ></textarea>
<p /><label for='f511' class='clslbl'>Describe what treatment you have received for this disability:</label>
<textarea class='f511' id='f511' name='TreatmentReceived' spellcheck='false' tabindex=163 title="Describe what treatment you have received for this disability:" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<div class='div_text202'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>6.6 Describe what treatment you have received for this disability: <br /></span></div>
<p /><label for='f517' class='clslbl'>What has been the result of this treatment?</label>
<textarea class='f517' id='f517' name='TreatmentResult' spellcheck='false' tabindex=164 title="What has been the result of this treatment?" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<div class='div_text203'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>6.7 What has been the result of this treatment? <br /></span></div>
<p /><label for='f529' class='clslbl'>What is your present condition?</label>
<textarea class='f529' id='f529' name='CurrentCondition' spellcheck='false' tabindex=165 title="What is your present condition?" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<div class='div_text204'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>6.8 What is your present condition? <br /></span></div>
<div class='f544_box'></div><p /><label for='f544' class='clslbl'>ConfinedTo - HOUSE</label>
<input type=RADIO class='f544' id='f544' name='ConfinedTo' value='HOUSE' tabindex=166 title="ConfinedTo - HOUSE" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f545_box'></div><p /><label for='f545' class='clslbl'>ConfinedTo - BED</label>
<input type=RADIO class='f545' id='f545' name='ConfinedTo' value='BED' tabindex=166 title="ConfinedTo - BED" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f546_box'></div><p /><label for='f546' class='clslbl'>ConfinedTo - NONE</label>
<input type=RADIO class='f546' id='f546' name='ConfinedTo' value='NONE' tabindex=166 title="ConfinedTo - NONE" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text215'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>The House <br /></span></div>
<div class='div_text216'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>The Bed <br /></span></div>
<div class='div_text217'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Neither <br /></span></div>
<div class='div_text205'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>6.9 Are you confined to: <br /></span></div>
<p /><label for='f564' class='clslbl'> If neither, give details of your present activities</label>
<textarea class='f564' id='f564' name='Confined_Details' spellcheck='false' tabindex=167 title=" If neither, give details of your present activities" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<div class='div_text206'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>If neither, give details of your present activities: <br /></span></div>
<div class='f571_box'></div><p /><label for='f571' class='clslbl'>Is any further treatment or operation contemplated? - 1</label>
<input type=RADIO class='f571' id='f571' name='FurtherTreatment' value='1' tabindex=168 title="Is any further treatment or operation contemplated? - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f572_box'></div><p /><label for='f572' class='clslbl'>Is any further treatment or operation contemplated? - 2</label>
<input type=RADIO class='f572' id='f572' name='FurtherTreatment' value='2' tabindex=168 title="Is any further treatment or operation contemplated? - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text209'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text210'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text207'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>6.10&nbsp;&nbsp;Is any further treatment or operation contemplated? <br /></span></div>
<p /><label for='f577' class='clslbl'> If YES, please give details</label>
<textarea class='f577' id='f577' name='FurtherTreatmentDetails' spellcheck='false' tabindex=169 title=" If YES, please give details" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<div class='div_text208'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>If YES, please give details: <br /></span></div>
<div class='div_line_583'></div>
<div class='div_text212'><div align='left'><span style='font: normal normal 7pt Arial;color:#000000;text-decoration: none'>Nedgroup Life Assurance Company Limited .Reg No 1993/001022/06 <br /></span></div><div align='left'><span style=''>1st Floor, Ridgeside Campus, 2 Ncondo Drive, Umhlanga Rocks, 4320; PO Box 149175, East End, 4018. <br /></span></div><div align='left'><span style=''>Tel 0860 263 543 Fax 0860 065 437 Website www.nedgrouplife.co.za. <br /></span></div></div>
<div class='div_line_594'></div>
<div class='div_text211'><span style='font: 7pt "Arial";color:#000000;text-decoration:none;'>Page 4 of 5 <br /></span></div>
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<div class='div_text220'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>SECTION 7 <br /></span></div>
<p /><label for='f52' class='clslbl'>How has your ability to follow your occupation been affected by this disability?</label>
<textarea class='f52' id='f52' name='How_Occupation_Affected' spellcheck='false' tabindex=170 title="How has your ability to follow your occupation been affected by this disability?" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<div class='div_text218'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>7.1 How has your ability to follow your occupation been affected by this disability? <br /></span></div>
<div class='div_text219'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>7.2 Current work status <br /></span></div>
<div class='f83_box'></div><p /><label for='f83' class='clslbl'>Current work status - 1</label>
<input type=RADIO class='f83' id='f83' name='Current_Work_Status' value='1' tabindex=171 title="Current work status - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f84_box'></div><p /><label for='f84' class='clslbl'>Current work status - 2</label>
<input type=RADIO class='f84' id='f84' name='Current_Work_Status' value='2' tabindex=171 title="Current work status - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f85_box'></div><p /><label for='f85' class='clslbl'>Current work status - 3</label>
<input type=RADIO class='f85' id='f85' name='Current_Work_Status' value='3' tabindex=171 title="Current work status - 3" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f86_box'></div><p /><label for='f86' class='clslbl'>Current work status - 4</label>
<input type=RADIO class='f86' id='f86' name='Current_Work_Status' value='4' tabindex=171 title="Current work status - 4" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f87_box'></div><p /><label for='f87' class='clslbl'>Current work status - 5</label>
<input type=RADIO class='f87' id='f87' name='Current_Work_Status' value='5' tabindex=171 title="Current work status - 5" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text221'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Still working <br /></span></div>
<div class='div_text222'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>On paid sick-leave <br /></span></div>
<div class='div_text223'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>On unpaid sick-leave <br /></span></div>
<div class='div_text224'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Retrenched <br /></span></div>
<div class='div_text225'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Under notice of termination of service <br /></span></div>
<p /><label for='f123' class='clslbl'>On what date were you last able to undertake any part of your occupational duties?</label>
<input type=TEXT value='' class='f123' id='f123' name='Date_Partaking_Duties' tabindex=172 title="On what date were you last able to undertake any part of your occupational duties?" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text268'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<div class='div_text226'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>7.3 On what date were you last able to undertake any part of your occupational duties? <br /></span></div>
<p /><label for='f142' class='clslbl'>On what date did you last actively engage in your occupation?</label>
<input type=TEXT value='' class='f142' id='f142' name='Date_Actively_Engaged' tabindex=173 title="On what date did you last actively engage in your occupation?" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text269'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<div class='div_text227'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>7.4 On what date did you last actively engage in your occupation? <br /></span></div>
<p /><label for='f150' class='clslbl'>If applicable, also the date of termination of service</label>
<textarea class='f150' id='f150' name='Image_43' spellcheck='false' tabindex=174 title="If applicable, also the date of termination of service" onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<div class='div_text228'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>If applicable, also the date of termination of service <br /></span></div>
<div class='f170_box'></div><p /><label for='f170' class='clslbl'>Will you be able in the future to resume in whole or in part your occupation mentioned in 1.3 to 1.5? - 1</label>
<input type=RADIO class='f170' id='f170' name='Will_Resume_Duties' value='1' tabindex=175 title="Will you be able in the future to resume in whole or in part your occupation mentioned in 1.3 to 1.5? - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f171_box'></div><p /><label for='f171' class='clslbl'>Will you be able in the future to resume in whole or in part your occupation mentioned in 1.3 to 1.5? - 2</label>
<input type=RADIO class='f171' id='f171' name='Will_Resume_Duties' value='2' tabindex=175 title="Will you be able in the future to resume in whole or in part your occupation mentioned in 1.3 to 1.5? - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text230'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text231'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text229'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>7.5 Will you be able in the future to resume in whole or in part your occupation mentioned in 1.3 to 1.5? <br /></span></div>
<p /><label for='f184' class='clslbl'> If YES when are you likely to be able to do so?</label>
<input type=TEXT value='' class='f184' id='f184' name='Date_Return_Occupation' tabindex=176 title=" If YES when are you likely to be able to do so?" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text270'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<div class='div_text232'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>7.5.1 If YES, when are you likely to be able to do so? <br /></span></div>
<p /><label for='f194' class='clslbl'> To what extent?</label>
<textarea class='f194' id='f194' name='To_What_Extent' spellcheck='false' tabindex=177 title=" To what extent?" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<div class='div_text233'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>7.5.2 To what extent? <br /></span></div>
<div class='div_text234'><div align='left'><span style='font: normal normal 8pt Arial;color:#000000;text-decoration: none'>7.5.3 If NO, please state what type of similar or other occupation you are likely to be able to follow taking into consideration your <br /></span></div><div align='left'><span style=''>knowledge, training and abilities. <br /></span></div></div>
<p /><label for='f219' class='clslbl'> If NO, please state what type of similar or other occupation you are likely to be able to follow taking into consideration your
 knowledge, training and abilities.</label>
<textarea class='f219' id='f219' name='Will_Not_Resume_Duties' spellcheck='false' tabindex=178 title=" If NO, please state what type of similar or other occupation you are likely to be able to follow taking into consideration your&#10; knowledge, training and abilities." onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f237' class='clslbl'>When are you likely to be able to commence a similar or different occupation?</label>
<input type=TEXT value='' class='f237' id='f237' name='Date_Similar_Occupation' tabindex=179 title="When are you likely to be able to commence a similar or different occupation?" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text235'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>7.6 When are you likely to be able to commence a similar or different occupation? <br /></span></div>
<div class='div_text271'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<div class='div_text236'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>7.7 Employment history <br /></span></div>
<div class='div_rect_274'></div>
<div class='div_line_276'></div>
<div class='div_line_277'></div>
<div class='div_line_278'></div>
<div class='div_text239'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>Date appointed <br /></span></div>
<div class='div_text237'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>Employer <br /></span></div>
<div class='div_text238'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>Job title <br /></span></div>
<div class='div_text240'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>Date and reason for leaving <br /></span></div>
<div class='div_text272'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<div class='div_line_287'></div>
<p /><label for='f288' class='clslbl'>Employment history Employer</label>
<textarea class='f288' id='f288' name='Employer_1' spellcheck='false' tabindex=180 title="Employment history Employer" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f289' class='clslbl'>Employment history Job Title?</label>
<textarea class='f289' id='f289' name='JobTitle_1' spellcheck='false' tabindex=181 title="Employment history Job Title?" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f290' class='clslbl'>Cell number</label>
<input type=TEXT value='' class='f290' id='f290' name='Employment_Date_1' tabindex=182 title="Cell number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<p /><label for='f291' class='clslbl'>Date_Reason_Leaving_1</label>
<textarea class='f291' id='f291' name='Date_Reason_Leaving_1' spellcheck='false' tabindex=183 title="Date_Reason_Leaving_1" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f295' class='clslbl'>Employment history Employer</label>
<textarea class='f295' id='f295' name='Employer_2' spellcheck='false' tabindex=184 title="Employment history Employer" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f296' class='clslbl'>Employment history Job Title?</label>
<textarea class='f296' id='f296' name='JobTitle_2' spellcheck='false' tabindex=185 title="Employment history Job Title?" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f297' class='clslbl'>Cell number</label>
<input type=TEXT value='' class='f297' id='f297' name='Employment_Date_2' tabindex=186 title="Cell number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<p /><label for='f298' class='clslbl'>Date_Reason_Leaving_2</label>
<textarea class='f298' id='f298' name='Date_Reason_Leaving_2' spellcheck='false' tabindex=187 title="Date_Reason_Leaving_2" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f306' class='clslbl'>Employment history Employer</label>
<textarea class='f306' id='f306' name='Employer_3' spellcheck='false' tabindex=188 title="Employment history Employer" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f307' class='clslbl'>Employment history Job Title?</label>
<textarea class='f307' id='f307' name='JobTitle_3' spellcheck='false' tabindex=189 title="Employment history Job Title?" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f308' class='clslbl'>Cell number</label>
<input type=TEXT value='' class='f308' id='f308' name='Employment_Date_3' tabindex=190 title="Cell number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<p /><label for='f309' class='clslbl'>Date_Reason_Leaving_3</label>
<textarea class='f309' id='f309' name='Date_Reason_Leaving_3' spellcheck='false' tabindex=191 title="Date_Reason_Leaving_3" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f313' class='clslbl'>Employment history Employer</label>
<textarea class='f313' id='f313' name='Employer_4' spellcheck='false' tabindex=192 title="Employment history Employer" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f314' class='clslbl'>Employment history Job Title?</label>
<textarea class='f314' id='f314' name='JobTitle_4' spellcheck='false' tabindex=193 title="Employment history Job Title?" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f315' class='clslbl'>Cell number</label>
<input type=TEXT value='' class='f315' id='f315' name='Employment_Date_4' tabindex=194 title="Cell number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<p /><label for='f316' class='clslbl'>Date_Reason_Leaving_4</label>
<textarea class='f316' id='f316' name='Date_Reason_Leaving_4' spellcheck='false' tabindex=195 title="Date_Reason_Leaving_4" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<div class='div_text241'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>7.8 Did any of the following contribute in any way to your disability? <br /></span></div>
<div class='f337_box'></div><p /><label for='f337' class='clslbl'>Previous illness, injury, mental or physical defect - 1</label>
<input type=RADIO class='f337' id='f337' name='Contribute_1' value='1' tabindex=196 title="Previous illness, injury, mental or physical defect - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f338_box'></div><p /><label for='f338' class='clslbl'>Previous illness, injury, mental or physical defect - 2</label>
<input type=RADIO class='f338' id='f338' name='Contribute_1' value='2' tabindex=196 title="Previous illness, injury, mental or physical defect - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text248'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text249'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text242'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>7.8.1 Previous illness, injury, mental or physical defect <br /></span></div>
<div class='f360_box'></div><p /><label for='f360' class='clslbl'>Hazardous occupation, pastimes or pursuits - 1</label>
<input type=RADIO class='f360' id='f360' name='Contribute_2' value='1' tabindex=197 title="Hazardous occupation, pastimes or pursuits - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f361_box'></div><p /><label for='f361' class='clslbl'>Hazardous occupation, pastimes or pursuits - 2</label>
<input type=RADIO class='f361' id='f361' name='Contribute_2' value='2' tabindex=197 title="Hazardous occupation, pastimes or pursuits - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text250'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text251'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text243'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>7.8.2 Hazardous occupation, pastimes or pursuits <br /></span></div>
<div class='f374_box'></div><p /><label for='f374' class='clslbl'>Failure to seek timely and adequate medical attention or to heed medical advice given - 1</label>
<input type=RADIO class='f374' id='f374' name='Contribute_3' value='1' tabindex=198 title="Failure to seek timely and adequate medical attention or to heed medical advice given - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f375_box'></div><p /><label for='f375' class='clslbl'>Failure to seek timely and adequate medical attention or to heed medical advice given - 2</label>
<input type=RADIO class='f375' id='f375' name='Contribute_3' value='2' tabindex=198 title="Failure to seek timely and adequate medical attention or to heed medical advice given - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text252'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text253'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text244'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>7.8.3 Failure to seek timely and adequate medical attention or to heed medical advice given <br /></span></div>
<div class='f389_box'></div><p /><label for='f389' class='clslbl'>Consumption of alcohol or the taking of drugs or narcotics (except under medical direction) - 1</label>
<input type=RADIO class='f389' id='f389' name='Contribute_4' value='1' tabindex=199 title="Consumption of alcohol or the taking of drugs or narcotics (except under medical direction) - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f390_box'></div><p /><label for='f390' class='clslbl'>Consumption of alcohol or the taking of drugs or narcotics (except under medical direction) - 2</label>
<input type=RADIO class='f390' id='f390' name='Contribute_4' value='2' tabindex=199 title="Consumption of alcohol or the taking of drugs or narcotics (except under medical direction) - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text254'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text255'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text245'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>7.8.4 Consumption of alcohol or the taking of drugs or narcotics (except under medical direction) <br /></span></div>
<div class='f405_box'></div><p /><label for='f405' class='clslbl'>Violation of the criminal law, wilful or negligent exposure to peril or provoked assault - 1</label>
<input type=RADIO class='f405' id='f405' name='Contribute_5' value='1' tabindex=200 title="Violation of the criminal law, wilful or negligent exposure to peril or provoked assault - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f406_box'></div><p /><label for='f406' class='clslbl'>Violation of the criminal law, wilful or negligent exposure to peril or provoked assault - 2</label>
<input type=RADIO class='f406' id='f406' name='Contribute_5' value='2' tabindex=200 title="Violation of the criminal law, wilful or negligent exposure to peril or provoked assault - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text256'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text257'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text246'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>7.8.5 Violation of the criminal law, wilful or negligent exposure to peril or provoked assault <br /></span></div>
<div class='f426_box'></div><p /><label for='f426' class='clslbl'>Attempted suicide or self-inflicted injury - 1</label>
<input type=RADIO class='f426' id='f426' name='Contribute_6' value='1' tabindex=201 title="Attempted suicide or self-inflicted injury - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f427_box'></div><p /><label for='f427' class='clslbl'>Attempted suicide or self-inflicted injury - 2</label>
<input type=RADIO class='f427' id='f427' name='Contribute_6' value='2' tabindex=201 title="Attempted suicide or self-inflicted injury - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text258'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text259'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text247'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>7.8.6 Attempted suicide or self-inflicted injury <br /></span></div>
<div class='div_text260'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>If you answered YES to any of these items, please give full details or circumstances: <br /></span></div>
<p /><label for='f458' class='clslbl'>   If you answered YES to any of these items, please give full details or circumstances:</label>
<textarea class='f458' id='f458' name='Deatils_of_Contribution' spellcheck='false' tabindex=202 title="&nbsp;&nbsp; If you answered YES to any of these items, please give full details or circumstances:" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,255);' onKeyDown = 'maxl(this,255);return EP_OKD(this,event);' ></textarea>
<div class='f498_box'></div><p /><label for='f498' class='clslbl'>Do you have medical aid? - 1</label>
<input type=RADIO class='f498' id='f498' name='MedicalAidQuestion' value='1' tabindex=203 title="Do you have medical aid? - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f499_box'></div><p /><label for='f499' class='clslbl'>Do you have medical aid? - 2</label>
<input type=RADIO class='f499' id='f499' name='MedicalAidQuestion' value='2' tabindex=203 title="Do you have medical aid? - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text266'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text267'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text265'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>7.9 Do you have medical aid? <br /></span></div>
<div class='div_text261'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Medical aid details:&nbsp;&nbsp; Name of fund <br /></span></div>
<p /><label for='f516' class='clslbl'> Name of fund</label>
<textarea class='f516' id='f516' name='Image_64' spellcheck='false' tabindex=204 title=" Name of fund" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f527' class='clslbl'> Membership no</label>
<textarea class='f527' id='f527' name='Image_65' spellcheck='false' tabindex=205 title=" Membership no" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<div class='div_text262'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Membership no <br /></span></div>
<div class='div_line_584'></div>
<div class='div_text264'><div align='left'><span style='font: normal normal 7pt Arial;color:#000000;text-decoration: none'>Nedgroup Life Assurance Company Limited .Reg No 1993/001022/06 <br /></span></div><div align='left'><span style=''>1st Floor, Ridgeside Campus, 2 Ncondo Drive, Umhlanga Rocks, 4320; PO Box 149175, East End, 4018. <br /></span></div><div align='left'><span style=''>Tel 0860 263 543 Fax 0860 065 437 Website www.nedgrouplife.co.za. <br /></span></div></div>
<div class='div_line_595'></div>
<div class='div_text263'><span style='font: 7pt "Arial";color:#000000;text-decoration:none;'>Page 5 of 5 <br /></span></div>
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